(St. Anthony’s fire; Ignis sacer)
Definition. An acute, contagious, specific inflammation of the skin and contiguous mucous membranes, characterized by sharply defined redness, swelling, heat and vesication, and accompanied by febrile and other systemic disturbances.
Symptoms. the prodromata may be mild or even wanting, or may consist of malaise, prostration, chills, vomiting, etc. The temperature varies from 101* to 106* F., and is persistent with an evening rise and morning remission, except in the mildest cases where it may subside after a few hours or days. A rise of fever usually indicates an extension of the disease and its arrest or fall, a subsidence of the same. The rapidity of the pulse is usually in proportion to the degree of fever and its other qualities depend not only upon the disease itself, but upon the previous conditions of the patient due to his habits or other disease. Headache is often a common symptom. Drowsiness and dizziness are not uncommon especially when the attack is limited to the head.
Local signs of erysipelas appear at the point of infection. The initial lesion is a small, red, shiny, swollen, irregular but sharply defined spot. the color disappears on pressure with the exception of a yellowish tinge, only to return quickly on removal of the finger. The color may remain a bright or scarlet red or become vilaceous or even livid. The part affected is painful, hot and tense, while the amount of swelling varies widely with the region affected, being greatest where the areolar tissue is abundant and loose and least where it is moderate and firm. When the face is involved, the eyes are often completely swollen while on the scalp it may cause only slight elevation. Although the area affected may spread at all or several points, it preserves a sharply defined border against the sound skin. The peripheral advanced may be somewhat erratic and occasionally is by apparent metastasis to another region. The surfaces involved may be large or small. Involution often goes on in the older portions as new areas are invaded and rarely a large part of the surface may be affected in this way (erysipelas ambulans or erysipelas migrans). Frequently a case will run its course without developing other lesions but when the process is sufficiently intense the pressure of exudation in the epidermis may rise to the surface in vesicles or blebs, the contents of which may even become purulent and dry up into crusts. Prolonged and intense compression of the capillaries of the skin may induce gangrene especially of the legs and arms. Red streaks along the skin show the lymphatic involvement and neighboring glands may suppurate or furunculous abscesses may form.
From a personal observation of about 1,600 cases of erysipelas, I have been impressed with the fact that the recurrent and chronic types are apparently rare, representing only about 5 per cent. of all cases. The same may be said of the post-operative cases which numbered only 58 in the total. Complications, or atypical clinical types, were also very rare. About three-fourths of my cases occurred upon the face, many originating at, or within the nasal orifice. these latter are usually of a slight and limited character and do not confine the patient. Local recovery is indicated by the disappearance of heat, swelling, redness and a variable degree of desquamation. Convalescence is uneventful, rapid and complete in the great majority of cases. The duration of erysipelas varies from one to three weeks and may exhibit all grades of severity. The temperature in the more typical cases will by crisis in from five to ten days although it may fall by lysis.
Etiology and Pathology. The etiological factors may be considered as essential, contributory and predisposing. The streptococcus erysipelatis of Fehleisen is the essential cause but it is not improbable that other microorganisms may produce inflammations presenting all the symptoms of erysipelas. The contributory element is represented by some break in the continuity of the skin or mucous membrane, however minute. Hence, any lesion of the surface may afford a starting point for erysipelas. Larger wounds from traumatisms or surgical operations are more readily affected and rather favor the assumption that no special condition of the tissues other than exposure is necessary to permit infection, but no doubt lessened resistance from alcoholism, debility or organic disease might be cited as a predisposing cause. One attack apparently predispose to another, although the true recurrent or chronic cases are comparatively few in my experience. Age is a factor for it is unusual in the young and old. Five- sevenths of my cases occurred between the age of twenty and fifty. It is also predominant among males in the proportion of two to one, due to their greater opportunity for infection from exposure, trauma, etc. It is more prevalent in the cold months, two-thirds of the cases occurring between December and May, and among those whose habits of living render them liable to infection. This is shown by the fact that in the large cities of the United States the foreign population contribute two-thirds of all cases.
The type of inflammation excited is serofibrinous, implicating chiefly the deeper portion of the corium and extending into the subcutaneous tissue. This latter exudation accounts largely for the induration always felt and its slow absorption during involution. The epidermis is penetrated and sometimes lifted up by the exudation; vesicles or blebs from deeply at or below the base of the granular layer; and the follicles may be penetrated and the sheaths dissected from the roots resulting in loss of the hair.
Diagnosis. A history of early chills and consecutive fever, with a sharply defined, red, swollen patch, spreading more or less steadily in a regular or irregular manner, should be sufficient to diagnose a typical erysipelas.
Eczema never presents systemic fever except in young children. The patches are not as swollen, bright red or sharply defined as in erysipelas. The vesicles which form on the surface are minute, thickly set and perhaps more perceptible to touch than to sight. Often the surface is dry and scaly and the whole process is attended with marked sensations of itching.
Erythema is acute, unattended with fever, or any tendency to creep out over the surface. Redness disappear wholly on pressure and quickly returns when the pressure is removed.
Dermatitis from ivy or such drugs as iodoform is free from systemic disturbance, often starts from several points and lacks the sharply defined border.
Urticaria is ephemeral and usually lacks marked systemic disturbance. It nearly always shows wheals or a history of wheals without tenderness but with pronounced sensations of itching or stinging. There are often marked signs of digestive or other functional disturbance.
Prognosis. The great majority of uncomplicated cases should entirely recover. Following extensive traumatisms from accidents, surgical operations, labor, etc., the probabilities are less favourable. Old age, general debility, existing disease or alcoholism are complicating conditions which diminish the prospects of cure and might prolong the attack. Among my cases, many of whom were the poorest specimens of the human species, the death rate has never exceeded 5 per cent. in a given year.
Treatment. Rest in bed is essential, together with a simple, nutritious and easily assimilated diet. The same care should be taken of erysipelas as is taken of any other contagious disease, as regards isolation, nursing and the use of necessary general or heart stimulants. Excellent results have followed a few injections of antistreptococcus serum (about 10 c.c.at a dose), in severe cases. The local treatment is most important, not only for the patient’s comfort and the prevention of contagion but as an essential for absolute cleanliness. Inasmuch as the microbe carries on its work deep in the tissues of the skin, external measures do not need to be dirty of disagreeable. The part should be continuously covered with a mask or layers of gauze saturated with one of the following solutions: mercuric chlorid (1:3000), 1 per cent. picric acid, 1 per cent. carbolic acid, 5 per cent. sodium salicylate, 95 per cent. alcohol, saturated solution of magnesium sulphate, a weak solution of calendula or hamamelis, or equal parts of alcohol and glycerin. The last is my favorite method because it is appreciated by the patient, giving the necessary comfort, and affords the essential germicide. when cellulitis or pus is present, a 1 to 8 per cent. of creolin in glycerin is the best external application. Although nearly every authority has reported some new local treatment for erysipelas, and ichthyol, iodin and many other solutions have been urged, none of them presents any advantage over the above mentioned. I have never observed that the application of silver nitrate or iodin to the border of the lesion or beyond it, stopped the disease. It is a useless and meddlesome practice. Blebs may be opened when extensive and pus formations and cellulitis may need surgical attention. A plain oil or ointment should be constantly applied in the desquamative stage. Every care should be taken to prevent the infection of attendants and other patients, especially surgical and puerperal cases and to prevent possible autoinfection.
From the observation of the large number of cases mentioned, both in hospital and private practice, I believe the value of the indicated remedy cannot be overestimate. In the simpler cases, beyond protective and soothing application, it is all that is necessary. While the number of drugs that may be indicated is large, there are a few that are more commonly used, such as Antipyrin, Apis, Arnica, Arsen., Belladonna, Cantharis, Crotal., Euphor., Kali bich., LAch., Nitric acid, Rhus tox., and Vipera.